tbuckley/cabot-search huggingface dataset:
Abstract 14613: Amyloidosis-Related Orthopedic Events, Low Plasma Transthyretin, and Risk of Cardiac Events
Authors: Anders M Greve, Mette Christoffersen, Louise S Hornstrup, Ruth Frikke-Schmidt, Borge G Nordestgaard, Anne Tybjaerg-hansen
Journal: Circulation (2022)

Introduction: Carpal tunnel syndrome, spinal stenosis, and biceps tendon rupture may precede cardiac transthyretin amyloidosis (ATTR-CA). Hypothesis: We tested the hypothesis that amyloidosis-related orthopedic events herald amyloidosis and cardiac events consistent with ATTR-CA through transthyretin destabilization. Methods: In observational analysis in the Copenhagen General Population Study (CGPS; n=93,637), we first tested whether amyloidosis-related orthopedic events at baseline were associated with amyloidosis and incident cardiac events consistent with ATTR-CA (heart failure, atrial fibrillation, myocardial infarction, or death), and whether a low plasma transthyretin was associated with a higher risk. In genetic analysis, in CGPS and the Copenhagen City Heart Study(CCHS) combined (n=102,496), we tested whether TTR genotypes associated with stepwise lower plasma transthyretin, marking lower transthyretin tetramer stability and higher amyloidogenic potential, was associated with both orthopedic and incident cardiac events, implying a common mechanistic background through transthyretin destabilization. Results: In individuals with versus without orthopedic events at baseline, hazard ratios (HRs) were 10.7 (95% CI: 3.9-29.3) for amyloidosis, and 1.3(1.1-1.4) for cardiac events. Furthermore, in individuals with orthopedic events at baseline, HRs for cardiac events were 3.8(1.9-7.6) in those with transthyretin &lt;20 mg/dL versus ≥20 mg/dL (Figure 1). Finally, HRs as a function of TTR genotype increased with lower transthyretin and lower transthyretin tetramer stability up to 3.0(1.4-6.6) for orthopedic events and 1.6(95% CI: 1.0-2.6) for cardiac events. Conclusion: Amyloidosis-related orthopedic events are associated with increased risk of incident cardiac events, with the highest risk in those with low transthyretin levels. Orthopedic and cardiac events are linked through transthyretin tetramer destabilization.
Abstract 13199: Transcatheter Valve Implantation in Reversed Potts Shunt in Pulmonary Arterial Hypertension: Keeping the Shunt Reversed
Authors: Ghazaleh Goldar, Joanna Ghobrial
Journal: Circulation (2022)

Case description: 19-year-old female with idiopathic PAH diagnosed at the age of 4 with surgical valved reversed Potts shunt (rPS), from the left pulmonary artery (LPA) to the descending aorta (DsAo), at the age of 16. In her case, the valved rPS was fashioned using a 10 mm Fusion graft (Getinge ® , Getinge, Sweden), and a 12 mm valved Contegra conduit (Medtronic ® , MN, USA) that was trimmed at a shorter length than the graft and positioned in the middle of it, leaving the distal edges of the graft intact at the smaller diameter. She presented in 2021 with decompensated right-sided heart failure requiring continuous oxygen supplementation and pressor and ionotropic support. Investigation: Echocardiography showed normal LV size and function, severe RV dilation and dysfunction with RVSP of 102 mmHg (SBP: 119 mmHg). New bidirectional flow across the valve within the rPS was noted. Management: Patient taken to the cardiac catheterization lab for valve implantation within the rPS. Her RA pressure was 11, RV 90/16, PA 90/45 (64) with a simultaneous aortic pressure of 90/56 (71), PCWP of 14, PA saturation of 60%, AsAo saturation of 84%, and DsAo saturation of 84%. Angiography showed bidirectional shunting and an incompetent deteriorated rPS valve. We modified the 18mm Ensemble ® transcatheter valve delivery system to fit a 20 mm Melody ® (Medtronic, MN, USA) valve, by removing the 18 mm balloon and using a15 mm balloon instead, maintaining the external sheath of the delivery system. Once the valve was crimped onto the balloon, we advanced it with the tip of the balloon slightly inflated over a stiff wire. After valve deployment, angiography demonstrated resolution of left to right shunting. Post valve deployment, her hemodynamics were stable as prior except for a drop in her PA saturation to 49%, and DsAo saturation to 80%. Discussion: rPS is designed to offload the RV in severe PAH. The bovine jugular valve in this case prevented left to right flow across rPS and thus pulmonary overcirculation, functioning as it was originally intended: a valved unidirectional rPS. This valve, while originally intended to be deployed to 18-22 mm in diameter in the pulmonary position, can be functional at diameters as narrow as 12-16 mm.
Abstract 13711: Cardiomyopathy Complicated by Constriction Resulting in Transplant Listing
Authors: Rylie Pietrowicz, Michel Ibrahim, Eman A Hamad, Val Rakita, Jamael Hoosain
Journal: Circulation (2022)

Introduction We describe a case of severe cardiomyopathy complicated by pericardial constriction resulting from epicardial VT ablation requiring heart transplant listing. Case Presentation A 43-year-old with a history of silent MI, LV aneurysm and thrombus, cardiomyopathy (EF 15%), Stage C heart failure, and VT on amiodarone initially presented with symptomatic VT requiring AICD therapy. He underwent epicardial ablation with no immediate complications. Post-ablation, he developed polymorphic VT prompting LHC revealing new LAD artery stenosis treated with stents. He was discharged on DAPT and warfarin. He subsequently re-presented with worsening dyspnea, lethargy, and edema. Invasive hemodynamics revealed elevated filling pressures and cardiogenic shock with constrictive physiology. Milrinone and aggressive diuresis were initiated with mild improvement in symptoms. Echocardiogram and cardiac MRI confirmed diagnosis of constrictive pericarditis and presence of hemopericardium. Discussion Multidisciplinary discussions were held to determine treatment. Management of constrictive pericarditis with pericardial stripping was considered. The high-risk nature of the procedure with unknown benefit, his age, and now Stage D heart failure made sternotomy a potential increased risk for future cardiac transplant. Ultimately, decision was made for pericardiocentesis, treatment with colchicine, a switch from triple therapy to warfarin and aspirin, and listing for transplant. Surveillance RHC 6 weeks post hospitalization showed resolution of constrictive physiology and normal cardiac output on milrinone.
Abstract 13180: Trans-Valvular Unloading Reduces Anaerobic Glycolysis Before Reperfusion and Preserves Energy Substrate Utilization After Reperfusion in Models of Acute Myocardial Infarction
Authors: Lija Swain, Xiaoying QIAO, Lara A Reyelt, Elric Zweck, Kay Everett, Monica Majumdar, Elena Mahmoudi, Shreyas Bhave, Nikolaos Diakos, Navin K Kapur
Journal: Circulation (2022)

Background: The impact of mechanical left ventricular (LV) unloading before reperfusion on myocardial energetics in acute myocardial infarction (AMI) is unknown. We hypothesized that LV unloading reduces anaerobic glycolysis in models of ischemia reperfusion injury (IRI). Methods: Myocardial ischemia was induced by percutaneous occlusion of the left anterior descending (LAD) artery for 90 minutes in adult swine. In Groups A and B, an additional 120 minutes of LAD occlusion without reperfusion was performed in the presence or absence of a trans-valvular pump (TVP). In Group C and D, an additional 120 minutes of reperfusion was performed in the presence or absence TVP (Fig. 1A). Untargeted Metabolomics was performed on the tissues from the infarct zones. Results: Compared to Group A, infarct size normalized to the area at risk (IS/AAR) was significantly smaller with LV unloading after ischemia alone (Group B; Fig 1B) and reperfusion (Group D; Fig 1B). Principal component analysis analysis of 800 metabolites identified 5 distinct clusters corresponding to the 4 study groups and sham controls (Fig 1C). LV unloading without reperfusion reduced lactate by 30±4% (p&lt;0.006), glucose by 25±5% (p&lt;0.02), and intermediates of glucose metabolism, Fructose 1,6-diphosphate by 9.3%, p&lt;0.008) and ATP by 14±5% (p&lt;0.04) consistent with decreased anaerobic glycolysis and reduced myocardial oxygen demand (Fig 1D Groups A and B). LV unloading followed by reperfusion increased lactate and glucose levels by 30±5% and 75±30% (p&lt;0.05). Consistent with reduced glycolytic metabolites during ischemia with unloading, we observed significantly reduced levels of genes and proteins associated with glycolysis including mRNA expression of Glut1 and PDK1 within the infarct zone.We report for the first time that LV unloading during coronary occlusion reduces anaerobic glycolysis, energy substrate utilization and ATP production before reperfusion.
Abstract 13312: Can the Extent of Late Gadolinium Enhancement on Cardiac Magnetic Resonance Be Predicted by the 12-Lead Electrocardiogram?
Authors: Chen Bao, Christopher Madias, Rachael Studley, Nadia Bokhari, Erick Quintana, Barry Maron, Martin S Maron, Martin Maron, Ethan J Rowin
Journal: Circulation (2022)

Background: In hypertrophic cardiomyopathy (HCM), late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is an in vivo marker of replacement fibrosis with a continuous relationship between amount of LGE and both risk for sudden death and development of endstage disease. Cost and accessibility can limit routine utilization of CMR. In contrast, electrocardiogram (ECG) is an inexpensive readily available test and identifies patients with myocardial scarring in ischemic heart disease. Its ability to identify presence and extent of LGE in HCM is unknown. Methods: 1983 consecutive HCM patients were included; 62% male, average wall thickness 18 ± 3mm, and 36% with resting LV outflow tract obstruction ≥ 30mmHg. ECGs were analyzed for LV hypertrophy, T wave abnormalities, ST-segment depression or elevations, abnormal Q waves, conduction disease, atrial enlargement and QTc prolongation. Extent of LGE was quantified and expressed as a proportion of total LV myocardium. Results: 822 (41%) had no LGE, while 1161 (59%) had LGE, including 687 (35%) with &lt;5%, 299 (15%) with 5-9%, 92 (5%) with 10-14%, and 83 (4%) with ≥ 15%. Compared to no LGE, Patients with LGE were more likely to have pathologic T wave inversions (55% vs. 36%, p&lt;0.01), positive T waves in aVR (34% vs. 20%, p&lt;0.01), and ST-depressions (29% vs. 21%, p&lt;0.01), with no difference in LV hypertrophy, bundle branch block, pathologic Q waves, first degree AV block, QTc prolongation ≥ 480ms, or ST-elevations (p&gt;0.05). Notably, as extent of LGE increased there was a corresponding progressive increase in the prevalence of both positive T waves in aVR (20% in no LGE to 42% in ≥ 15% LGE, p&lt;0.01) and pathologic T wave inversions (36% in no LGE to 61% in ≥ 15% LGE, p&lt;0.01) but with no incremental differences in ST depressions (p&gt;0.05). In contrast, 43% of patients with LGE did not have either positive T waves in aVR or pathologic T wave inversions, including 34% with ≥ 15% LGE. Conclusion: Most ECG findings including pathologic Q waves have no relation to presence or extent of LGE. While positive T waves in aVR and pathologic T wave inversions are associated with LGE, they have limited sensitivity. These finding support that routinely evaluated ECG abnormalities do not predict presence or extent of scarring in HCM.
Abstract 13239: Variation in Cost by HEART Score in Patients With Suspected Acute Coronary Syndrome
Authors: Aniket A Kawatkar, Adam Sharp, Aileen Baecker, Rita F Redberg, Mingsum Lee, Maros Ferencik, Steve Goodacre, Praveen Thokala, Yi-Lin Wu, Ernest Shen, chengyi zheng, Visanee Musigdilok, Benjamin Sun
Journal: Circulation (2022)

Introduction: The variation in medical cost by risk stratification using history, electrocardiogram, age, risk factors and troponin (HEART), after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), is not well understood. Hypothesis: We hypothesized that annual total all cause cost will increase significantly with increasing HEART score and the primary driver of the total cost will be cardiovascular disease (CVD) related care. Methods: This was a retrospective cohort study of adults (age ≥18) with chest pain and complete data for HEART score, presenting at EDs within the Kaiser Permanente Southern California health system from 1/2016-12/2018. We analyzed direct medical cost associated with medical office visits, hospital facility and ED visits, pharmacy utilization, hospice stays, skilled nursing stays, home health, dialysis, laboratory, and radiology utilization during the 1-year following the index ED visit. Stratified by HEART score categories, we used one part and two part generalized linear models (log link &amp; gamma family distribution) adjusted for socio-demographics, cardiovascular disease (CVD) history and treatment and non-CVD comorbidities, to estimate average adjusted total all cause expenditure as well as subgroups of utilization. Results: The cohort included 33,990 patients (60% Low risk; 37% intermediate risk and 3% high risk). The adjusted annual total cost varied from $6,544 (95% CI $6,228 to $6,860) in the low risk to $21,210 ($19,458 to $22,962) in the high-risk group (Table 1). In each group, the primary driver of total cost was CVD related care accounting for 41% to 46% of total cost. CVD care provided in a hospital setting accounted for 44%-76% of CVD total cost. Conclusions: Increased follow-up medical office visits, improved medications and lifestyle management may reduce the near exponential increase in cost driven by catastrophic hospital utilization, in higher HEART risk stratified patients.
Abstract 14459: Case Report: Unusual Presentation of <i>Cardiobacterium Hominis</i> Bioprosthetic Valve Endocarditis
Authors: Priya Nigam, Christiane Mhanna, A. Majeed Bhat, Karen O'Neil, Matthew J Campbell
Journal: Circulation (2022)

Introduction: Cardiobacterium hominis , part of the oropharyngeal flora, is a gram-negative bacteria reported to cause infection in less than 5% of patients with infective endocarditis (IE). In children, congenital heart disease (CHD) is a predominant risk factor for developing IE. Herein we describe an unusual presentation of C. hominis bioprosthetic valve endocarditis. Case Presentation: A 23-year-old woman with bicuspid aortic valve and aortic valve stenosis underwent aortic bioprosthetic valve placement in 2017. In March 2022, she presented to an emergency room with left lower abdominal pain. A CT scan demonstrated occlusion of the left iliac artery. Medications at that time included oral contraceptive pills and baby aspirin. No echocardiogram was obtained at that visit. She presented for a routine cardiology follow-up in May 2022 at which time she was asymptomatic. Transthoracic echocardiogram demonstrated moderate to severe aortic insufficiency, though the mechanism could not be delineated. There was concomitant development of mild mitral valve and tricuspid valve insufficiency. She denied dyspnea, chest pain, or fevers. Laboratory investigation showed mild elevation of CRP and a normal ESR. A transesophageal echocardiogram demonstrated that the severe aortic regurgitation was through a paravalvar leak (figure 1). There was no evidence of vegetations. Three separate blood cultures grew C. hominis . The patient was admitted for IV antibiotic therapy prior to bioprosthetic replacement. Conclusions: C. hominis is an infrequent cause of endocarditis and most cases present with fever and elevated ESR. This patient had an unusual presentation with left iliac thrombus, which in retrospect was likely due to embolism of a vegetation. She also developed aortic bioprosthetic paravalvar leak. This case highlights the need for a high degree of suspicion for endocarditis in patients with CHD and bioprosthetic valves.
Abstract 13357: From Junctional Rhythm to Slow Vt: Flecainide Poisoning
Authors: Hanyuan Shi, Rui Zhang, Prajesh Gongal, Daniel Feldman, Alexandra Ortengren, Athos Rassias, Rajbir Sangha, Rohitha Moudgal, Stanislav Henkin
Journal: Circulation (2022)

Introduction: Flecainide is a class IC anti-arrhythmic used to treat atrial fibrillation. Toxicity can cause bradycardia, QRS prolongation, and ventricular tachyarrhythmia (VT) due to blockade of sodium channels. Although most metabolism occurs through the liver, up to 30% excretion is renal but not dialyzable. The case here represents two arrhythmogenic challenges associated with flecainide treated with alkalization and lipid emulsion. Case: A 75-year-old woman with atrial fibrillation initially presented with syncope and hematemesis. Initial ECG showed junctional bradycardia with narrow escape in HR 30s. Labs notable for creatinine 2.55 (nl &lt;1.2 mg/dl) and potassium 4.8 (3.5-5.0 mmol/L). pH was 7.28 with bicarbonate 18 (22-31 mmol/L). She was treated with glucagon and atropine for suspected B-blocker toxicity but quickly went into shock. Rhythm then changed to a wide complex tachycardia (Fig) with wide QRS 280ms, VT rates in 100s. Due to development of this slow VT, flecainide toxicity was highly suspected, and a bicarbonate drip was started to maintain pH&gt;7.50 in addition to intralipid infusion. In the span of 12 hours, she was able to wean off her vasopressor support. On hospital day 3, she started metoprolol and remained in sinus bradycardia at the time of discharge. Discussion: This case represented acute renal failure secondary to flecainide toxicity and gastrointestinal bleed. Toxicity led to QRS widening and slow VT, which diminished contractility. Serum alkalization and sodium load works to displace flecainide from its channel receptor; intralipid sequesters lipophilic toxin in a “lipid sink” mechanism. In extreme cases, ECMO and overdrive pacing are used. Conclusions: Early recognition of flecainide-related arrhythmias is key. The subsequent approach to flecainide toxicity includes reducing absorption (charcoal, lipid emulsion), antagonizing drug effect (alkalization), and proving hemodynamic support (phenylephrine, vasopressin).
Abstract 13211: Dysregulated Myocardial Calcium Handling is a Driver of Early Heart Failure in Type 1 and Type 2 Diabetes
Authors: Shruti S Joshi, Abhishek Dattani, Gaurav Gulsin, Trisha Singh, Lucy Kershaw, Jian Yeo, Anvesha Singh, Emer Brady, Nick Spath, Kelly Parke, Jayanth Arnold, Rebecca Reynolds, Shareen Forbes, Fraser Gibb, Michelle Williams, Scott Semple, MARC DWECK, Gerry McCann, David E Newby
Journal: Circulation (2022)

Introduction: Dysregulated myocardial calcium handling may be a precursor for heart failure in type 1 (T1D) and type 2 diabetes (T2D). Manganese-enhanced magnetic resonance imaging (MEMRI) is a novel non-invasive method of assessing in vivo myocardial calcium handling. Hypothesis Myocardial calcium handling is impaired in patients with either T1D or T2D, despite normal left ventricular (LV) systolic function. Methods Prospective, multicentre, study in patients with T1D (n=19), T2D (n=30), and healthy volunteers (n=28), all of whom were free of known cardiovascular disease. Cardiac MRI was performed including MEMRI, during which T1 mapping was performed at baseline and every 2.5 min for 30 min after manganese infusion (Figure 1a). The rate of myocardial manganese uptake, determined by Patlak modelling [1]. Results No difference in LV systolic function was observed between groups, but those with T2D had more concentric LV remodelling compared to T1Ds and healthy volunteers (LV mass:volume 0.90±0.16 vs. 0.75±0.09 vs. 0.74±0.10 g/mL, respectively; p=0.001, Table 1). Mean myocardial manganese uptake was significantly lower in both T1Ds (6.47±0.99 mL/100g/min) and T2Ds (6.43±0.77 mL/100g/min) compared with healthy volunteers (8.33±0.77 mL/100g/min; p&lt;0.001 for both, Figure 1b). Conclusion For the first time, we have demonstrated that myocardial calcium handling is impaired in patients with either T1D or T2D despite apparently normal LV systolic function. This may be a precursor to the development of diabetic cardiomyopathy and has implications for developing novel therapeutic targets for its prevention and treatment. [1] Skjold, A et al. J Magn Reson Imag 2006;24:1047-1055 graphic_{ECFA3EC4-96D0-4ADC-8599-3D854C84F04F}graphic_{F1770AC6-718C-4C39-B107-4A5DD60957A8}
Abstract 13878: A Case of Severe Tricuspid Regurgitation, Recurrent Ascites, Worsening Renal Function Leading to Hemodialysis Secondary to RV Lead Impingement, Resolved Completely With Lead Extraction
Authors: likhitesh jaikumar, Anju Priyadarshini, Vivek Menon, Anjula Chib, Sasha Sharifi, Paul Volansky, Sandra Charlton, MANDAR JAGTAP DO, Frank A McGrew
Journal: Circulation (2022)

Introduction: 1. In contemporary practice, implantation of Cardiovascular Implantable Electronic Devices (CIED) is associated with low complication rate peri-procedurally. 2. However, in some patients these complications can have high morbidity and mortality; namely pneumothorax, pericardial tamponade, pacemaker syndrome, and rarely tricuspid regurgitation (TR) secondary to lead impingement. 3. TR secondary to RV lead impingement is not uncommon but infrequently lead to severe TR and worsening heart failure symptoms. 4. We present a case of severe TR secondary to RV lead impingement leading to splanchnic congestion and recurrent ascites, worsening renal failure leading to hemodialysis (HD), all of which resolved with lead extraction. Case: A 77-year-old woman with known CAD with prior PTCA, paroxysmal AF, and prior watchman implantation, evaluated in our clinic for severe TR. She had recurrent admissions for ascites needing paracentesis. Her liver function and ultrasound was normal. Her renal function worsened and HD was initiated. ECHO showed normal LVEF, severe TR with RVSP of 74mmHg, and mild RV dysfunction. Pericardial physiology was normal. The lead was noted to be impinging on the septal leaflet, and adherent. Normal pulmonary valve function. Follow up: We proceeded to perform RV lead extraction and implanted a new leadless pacemaker [MICRA-AV, Medtronic Inc]. Her follow up ECHO in 2 weeks showed mild TR and normal RV function. RVSP had dropped significantly to 34mmHg. Surprisingly, her needs for paracentesis came down and by 3 months follow up she did not need paracentesis anymore. Her renal function improved, and her HD needs stopped. Conclusions: 1. CIED implantations are associated with low complication rate (less than 5% in total) in most patient cohorts but in some patients it can be associated with significant complications increasing their morbidity and sometimes mortality. 2. Severe TR is a well-recognized complication of pacemaker implantation. It led to recurrent ascites needing paracentesis, ESRD requiring HD and multiple hospital admissions and thus increasing the morbidity. 3. It is important to recognize the uncommon complications of such commonly used intracardiac devices for electrophysiologists, cardiologists and PCPs.